Antibiotic use and prescription and its effects on Enterobacteriaceae in the gut in children with mild respiratory infections in Ho Chi Minh City, Vietnam. A prospective observational outpatient study.

BACKGROUND AND OBJECTIVES: Treatment guidelines do not recommend antibiotic use for acute respiratory infections (ARI), except for streptococcal pharyngitis/tonsillitis and pneumonia. However, antibiotics are prescribed frequently for children with ARI, often in absence of evidence for bacterial infection. The objectives of this study were 1) to assess the appropriateness of antibiotic prescriptions for mild ARI in paediatric outpatients in relation to available guidelines and detected pathogens, 2) to assess antibiotic use on presentation using questionnaires and detection in urine 3) to assess the carriage rates and proportions of resistant intestinal Enterobacteriaceae before, during and after consultation. MATERIALS AND METHODS: Patients were prospectively enrolled in Children's Hospital 1, Ho Chi Minh City, Vietnam and diagnoses, prescribed therapy and outcome were recorded on first visit and on follow-up after 7 days. Respiratory bacterial and viral pathogens were detected using molecular assays. Antibiotic use before presentation was assessed using questionnaires and urine HPLC. The impact of antibiotic usage on intestinal Enterobacteriaceae was assessed with semi-quantitative culture on agar with and without antibiotics on presentation and after 7 and 28 days. RESULTS: A total of 563 patients were enrolled between February 2009 and February 2010. Antibiotics were prescribed for all except 2 of 563 patients. The majority were 2nd and 3rd generation oral cephalosporins and amoxicillin with or without clavulanic acid. Respiratory viruses were detected in respiratory specimens of 72.5% of patients. Antibiotic use was considered inappropriate in 90.1% and 67.5%, based on guidelines and detected pathogens, respectively. On presentation parents reported antibiotic use for 22% of patients, 41% of parents did not know and 37% denied antibiotic use. Among these three groups, six commonly used antibiotics were detected with HPLC in patients' urine in 49%, 40% and 14%, respectively. Temporary selection of 3rd generation cephalosporin resistant intestinal Enterobacteriaceae during antibiotic use was observed, with co-selection of resistance to aminoglycosides and fluoroquinolones. CONCLUSIONS: We report overuse and overprescription of antibiotics for uncomplicated ARI with selection of resistant intestinal Enterobacteriaceae, posing a risk for community transmission and persistence in a setting of a highly granular healthcare system and unrestricted access to antibiotics through private pharmacies. REGISTRATION: This study was registered at the International Standard Randomised Controlled Trials Number registry under number ISRCTN32862422: http://www.isrctn.com/ISRCTN32862422.

Identification of Amoxicillin Crystals in Urine: a Case Report.

BACKGROUND: The case concerns a 30-year-old woman in the 24th week of pregnancy presenting to the medical emergency room with fever and abdominal pain. Urine sediment microscopy revealed the presence of unknown needle-shaped crystals. METHODS: Crystals identification was performed by Fourier-Transform Infrared Spectroscopy coupled to Attenuated Total Reflectance (FTIR-ATR). RESULTS: Amoxicillin crystals were verified with semiquantitative results of 87.7%. CONCLUSIONS: Drug-induced crystalluria is a frequent finding in urine examination and it may be asymptomatic. FTIR spectroscopy is a rapid and specific tool in identification of crystals and could be useful supporting renal disease diagnosis and monitoring drug therapy.

A new electrochemical platform based on low cost nanomaterials for sensitive detection of the amoxicillin antibiotic in different matrices.

A new electrochemical device based on a combination of nanomaterials such as Printex 6L Carbon and cadmium telluride quantum dots within a poly(3,4-ethylenedioxythiophene) polystyrene sulfonate film was developed for sensitive determination of amoxicillin. The morphological, structural and electrochemical characteristics of the nanostructured material were evaluated using X-ray diffraction, confocal microscopy, transmission electron microscopy and voltammetric techniques. The synergy between these materials increased the electrochemical activity, the electron transfer rate and the electrode surface area, leading to a high magnitude of the anodic peak current for the determination of amoxicillin. The electrochemical determination of the antibiotic was carried out using square-wave voltammetry. Under the optimised experimental conditions, the proposed sensor showed high sensitivity, repeatability and stability to amoxicillin determination, with an analytical curve in the amoxicillin concentration range from 0.90 to 69 µmol L-1, and a low detection limit of 50 nmol L-1. No significant interference in the electrochemical signal of amoxicillin was observed from potential biological interferences and drugs widely used, such as uric acid, paracetamol, urea, ascorbic acid and caffeine. It was demonstrated that without any sample pre-treatment and using a simple measurement device, the sensor could be an alternative method for not only the analysis of pharmaceutical products (commercial tablets) and clinical samples (urine), but also to examine food quality (milk samples).

Use of Polymer Inclusion Membranes (PIMs) as support for electromembrane extraction of non-steroidal anti-inflammatory drugs and highly polar acidic drugs.

The use of polymer inclusion membranes (PIMs) as support of 1-octanol liquid membrane in electromembrane extraction (EME) procedure is proposed. Synthesis of PIMs were optimized to a composition of 29% (w/w) of cellulose triacetate as base polymer and 71% (w/w) of Aliquat®336 as cationic carrier. Flat PIMs of 25µm thickness and 6mm diameter were used. EME protocol was implemented for the simultaneous extraction of four non-steroidal anti-inflammatory drugs (NSAIDs) (salicylic acid, ketoprofen, naproxen and ibuprofen) and four highly polar acidic drugs (anthranilic acid, nicotinic acid, amoxicillin and hippuric acid). Posterior HPLC separation of the extracted analytes was developed with diode array detection. Recoveries in the 81-34% range were obtained. EME procedure was applied to human urine samples.

Acute renal failure secondary to drug-related crystalluria and/or drug reaction with eosinophilia and systemic symptom syndrome in a patient with metastatic lung cancer.

Drug reaction with eosinophilia and systemic symptoms (DRESS) or drug-induced hypersensitivity is a severe adverse drug-induced reaction. Aromatic anticonvulsants, such as phenytoin, phenobarbital, and carbamazepine, and some drugs, can induce DRESS. Atypical crystalluria can be seen in patients treated with amoxycillin or some drugs and can cause acute renal failure. We describe a 66-year-old man who presented fever and rash and acute renal failure three days after starting amoxycillin. He was also using phenytoin because of cerebral metastatic lung cancer. Investigation revealed eosinophilia and atypical crystalluria. The diagnosis of DRESS syndrome was made, amoxicillin was stopped, and dose of phenytoin was reduced. No systemic corticosteroid therapy was prescribed. Symptoms began to resolve within three to four days. The aim of this paper is to highlight the importance of microscopic examination of urine in a case with acute renal failure and skin lesions to suspect DRESS syndrome.

Comprehensive study on the electrocatalytic effect of copper - doped nano-clinoptilolite towards amoxicillin at the modified carbon paste electrode - solution interface.

In this work, Cu(II)-exchanged clinoptilolite nanoparticles (Cu(II)-NCL) were prepared and characterized by FTIR, BET, XRD and TEM techniques. The obtained Cu(II)-NCL was then used for the modification of carbon paste electrode (CPE). The resulted Cu(II)-NCL/CPE was finally used for the voltammetric determination of amoxicillin (AMX). The best voltammetric response was obtained by the electrode containing 20% of the modifier in 0.05molL-1 NaCl at pHs 2.2 and 7.2. The electrode showed a linear response in the concentration range of 4.0×10-8-1.0×10-4molL-1 AMX with a detection limit of 2.0×10-8molL-1 in square wave voltammetry. The electrode showed good repeatability, reproducibility, long life time confirmed by statistical tests. The electrode had also good selectivity together with good applicability in determination of AMX in urine and pharmaceutical tablets as real samples.

New nanostructured support for carrier-mediated electromembrane extraction of high polar compounds.

A new support has been proposed to be used for carrier-mediated electromembrane extraction purposes. The new support (Tiss®-OH) is a 100µm thickness sheet nanofiber membrane manufactured by electrospinning and composed by acrylic nanofibers. It has been used in an electromembrane extraction (EME) combined with a HPLC procedure using diode array detection. The proposed method has been used for the extraction of four high polarity acidic compounds: nicotinic acid, amoxicillin, hippuric acid and salicylic acid. Analytes were extracted from an aqueous sample solution (pH 4) (donor phase) using a Tiss®-OH sheet that supports a 5% (w/v) Aliquat®336 in 1-octanol liquid membrane. Aqueous solution (pH 6) was used as acceptor phase. The electrical field was generated from a d.c. electrical current of 100V through two spiral shaped platinum wires placed into donor and acceptor phases. Analytes were extracted in 10min with recoveries in the 60-85% range. The proposed EME procedure has been successfully applied to the determination of the target analytes in human urine samples.

Rapid and Simultaneous Quantitation of Amoxicillin and Clavulanic Acid in Human Plasma and Urine by Ultra-Performance Liquid Chromatography Tandem Mass Spectrometry and Its Application to a Pharmacokinetic Study.

Rapid, accurate and sensitive ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) methods were developed and validated for the simultaneous quantitation of amoxicillin and clavulanic acid in human plasma and urine samples. Amoxicillin and clavulanic acid in both plasma and urine were extracted using a solid-phase extraction method. The compounds were separated on an Acquity UPLC HSS T3 column (2.1 × 100 mm, 1.8 µm). Ampicillin was used as the internal standard (IS) in plasma, while amoxicillin-d4 and sulbactam were used as ISs in urine. The lower limit of quantitation was 0.0500 and 0.0250 µg/mL for amoxicillin and clavulanic acid in plasma, and 0.0500 µg/mL for both analytes in urine. The established methods were validated in terms of selectivity, precision, accuracy, linearity, matrix effect, recovery, carryover, interaction, dilution integrity and stability, and successfully applied to a pharmacokinetic study of amoxicillin sodium and clavulanate potassium (10:1) injection in healthy volunteers.

Solid phase extraction of amoxicillin using dibenzo-18-crown-6 modified magnetic-multiwalled carbon nanotubes prior to its spectrophotometric determination.

This work reports on a method for selective extraction and sensitive determination of amoxicillin drug (AMX). The method is based on solid phase extraction of AMX by a novel modified magnetic nanoadsorbent prior to spectrophotometric determination of AMX using a procedure based on formation a colored azo-derivative of the investigated drug. The nanoadsorbent has been synthesized by modification of magnetic-multiwalled carbon nanotube with dibenzo-18-crown-6 moieties. The synthesized nanoparticles were characterized using TEM, XRD and FT-IR measurements. At the next step, various factors that could potentially affect adsorption and desorption efficiencies of AMX, have been optimized. The results showed that under the optimized conditions, sensitive and selective determination of the investigated drug in concentration range of 5.0-1000.0 ng mL(-1) with the limit of detection of 3.0 ng mL(-1) was achievable. Furthermore, the real sample analysis (i.e. amoxicillin capsules and human urine samples) results indicated that a reliable promising candidate method has been developed for the determination of AMX in the investigated real samples.

Amoxicillin-associated interference in an HPLC-EC assay for urinary fractionated metanephrines: potential pitfall in pheochromocytoma biochemical diagnosis.

OBJECTIVE: Measurement of urinary fractionated metanephrines represents a first-line test for the biochemical diagnosis of pheochromocytoma. The high performance liquid chromatography coupled to electrochemical detection (HPLC-EC) assays used in the routine clinical laboratory can be subjected to analytical interferences by the presence of drugs or their metabolites. In this paper we describe the interference on urinary normetanephrine (uNMN) caused by amoxicillin. DESIGN AND METHODS: Two pediatric patients suspected of pheochromocytoma had very high uNMN levels (2543 and 4227µg/g Cr respectively; upper reference value: 339µg/g Cr). Amoxicillin interference was assessed by comparison for co-elution with uNMN and by LC-MS/MS analysis. RESULTS: After amoxicillin interference was suspected and the therapy was stopped uNMN levels returned to normal (149 and 214µg/g Cr respectively). Chromatograms obtained by HPLC-EC clearly showed that amoxicillin co-elutes with uNMN. Patients' uNMN levels measured by LC-MS/MS were in the normal range. CONCLUSION: Amoxicillin is responsible for analytical interference on HPLC-EC assay for uNMN. This finding can be of help in distinguishing true-positive from false-positive results in the course of a biochemical diagnosis for pheochromocytoma.

Effect of chronic lead intoxication on the distribution and elimination of amoxicillin in goats.

A study of amoxicillin pharmacokinetics was conducted in healthy goats and goats with chronic lead intoxication. The intoxicated goats had increased serum concentrations of liver enzymes (alanine aminotransferase and γ-glutamyl transferase), blood urea nitrogen, and reactivated δ-aminolevulinic acid dehydratase compared to the controls. Following intravenous amoxicillin (10 mg/kg bw) in control and lead-intoxicated goats, elimination half-lives were 4.14 and 1.26 h, respectively. The volumes of distribution based on the terminal phase were 1.19 and 0.38 L/kg, respectively, and those at steady-state were 0.54 and 0.18 L/kg, respectively. After intramuscular (IM) amoxicillin (10 mg/kg bw) in lead-intoxicated goats and control animals, the absorption, distribution, and elimination of the drug were more rapid in lead-intoxicated goats than the controls. Peak serum concentrations of 21.89 and 12.19 µg/mL were achieved at 1 h and 2 h, respectively, in lead-intoxicated and control goats. Amoxicillin bioavailability in the lead-intoxicated goats decreased 20% compared to the controls. After amoxicillin, more of the drug was excreted in the urine from lead-intoxicated goats than the controls. Our results suggested that lead intoxication in goats increases the rate of amoxicillin absorption after IM administration and distribution and elimination. Thus, lead intoxication may impair the therapeutic effectiveness of amoxicillin.

Electrode-assisted desorption electrospray ionization mass spectrometry.

A new ion source has been developed for rapid, noncontact analysis of materials at ambient conditions. The method provides desorption of analytes under ambient conditions directly from different surfaces with little or no sample preparation. The new method, termed electrode-assisted desorption electrospray ionization (EADESI), is on the basis of the ionization of molecules on different surfaces by highly charged droplets produced on a sharp-edged high voltage tip, and ions produced are introduced into the mass spectrometer through a capillary. The EADESI technique can be applied to various samples including amino acids, peptides, proteins, drugs and human fluids such as urine and blood. EADESI is promising for routine analyses in different fields such as forensic, environmental and material sciences. EADESI interface can be fit to a conventional ion-trap mass spectrometer. It can be used for various types of samples with a broad mass range. EADESI can also provide real-time analysis which is very valuable for biomedical applications.

Pharmacokinetics of amoxicillin in human urine using online coupled capillary electrophoresis with electrogenerated chemiluminescence detection.

A novel and sensitive method for the determination of amoxicillin (AM) in human urine has been established using capillary electrophoresis (CE) coupled with electrochemiluminescence (ECL) detection, based on the ECL enhancement of Tris(2,2'-bipyridyl) ruthenium(II) with AM. The effects of several factors such as the detection potential, the concentration and the pH of phosphate buffer, the electrokinetic voltage and the injection time were investigated. Under the optimal conditions, the linear concentration of AM ranged from 1.0 ng/ml to 8.0 microg/ml (with a correlation coefficient of 0.9999). The limit of detection was 0.31 ng/ml. The mean recovery was 95.77% with relative standard deviations of no larger than 2.2%. This method is quick (the total run time within 6 min). This method has been successfully applied to a pharmacokinetic study in human urine after oral administration of AM.

Development and validation of a method to determine amoxicillin in physiological fluids using micellar liquid chromatography.

A simple and robust method was developed for the routine identification and quantification of amoxicillin by micellar LC. Amoxicillin, a beta-lactamase inhibitor, is one of the most commonly prescribed drugs in the treatment of urine and skin structure infections. In this work, amoxicillin was determined in urine samples without any pretreatment step in a phenyl column using a micellar mobile phase of 0.10 M SDS and 4% butanol at pH 3. A UV detection set at 210 nm was used. Amoxicillin was eluted at 5.1 min with no interference by the protein band or endogenous compounds. Linearities (r >0.9998), intra- and interday precisions were determined (RSD (%) 0.4-2.7% and 0.3-5%, respectively, in micellar media, and 0.14-2.6% and 0.13-6%, respectively, in urine), and robustness was studied in the method validation. LOD and LOQ were 0.04 and 0.1 microg/mL in micellar media and 0.14 and 0.34 microg/mL in urine, respectively. Recoveries in the urine matrix were in the range of 95-110%. The validated method proved to be reliable and sensitive for the determination of amoxicillin in urine samples.

Selective solid-phase extraction of amoxicillin and cephalexin from urine samples using a molecularly imprinted polymer.

In this paper we describe, for the first time, a molecularly imprinted polymer (MIP) for the antibiotic amoxicillin (AMX), synthesised by a noncovalent molecular imprinting approach and used to extract AMX selectively from urine samples. The MIP was applied as a molecularly selective sorbent in molecularly imprinted SPE (MISPE) in an off-line mode, where it showed useful cross-selectivity for a structurally related antibiotic, cephalexin (CPX). By using a MISPE protocol, the MIP was able to selectively extract both AMX and CFX from 5 mL of water spiked with 10 mg/L with recoveries of 75 and 78% for AMX and CFX, respectively. When applied to real samples (urine) at clinically relevant concentrations, recoveries from 2 mL of human urine spiked with 20 mg/L decreased slightly to 65 and 63% for AMX and CFX, respectively. To demonstrate further the selectivity of the MIP obtained, a comparison with commercially available SPE cartridges was performed. Improvements in the retention of both AMX and CFX on the MIP were obtained relative to the commercially available cartridges, and the MISPE extracts were considerably cleaner, due to molecularly selective analyte binding by the MIP.

Development of amoxicillin enzyme-linked immunosorbent assay and measurements of tissue amoxicillin concentrations in a pigeon microdialysis model.

A sensitive ELISA was developed for the detection of amoxicillin (AMX) in serum, urine, and milk. The ELISA used an indirect competitive method produced by coating the plate with ovalbumin conjugated with AMX hapten. Antibodies against AMX-BSA were detected by a goat-antirabbit antibody conjugated with peroxidase. Calibration standard curves ranged from 1.28 ng/mL to 20 microg/mL [IC(50) (inhibition concentration 50%) = 100 ng/mL], and the limits of detection were 1.3, 2.7, and 4.8 ng/mL for urine, milk, and serum, respectively. The intra- and interassay variations were less than 4 and 9.6%. The antibody produced against AMX cross-reacted highly with penicillin G (77%); cross-reacted moderately with ampicillin, oxacillin, and cloxacillin (56.9, 51.4, and 48.8%, respectively); but was considered non-cross-reactive with dicloxacillin (7.4%), cefadroxil (<1%), and cefazolin (<1%). Concentrations of AMX were measured simultaneously in venous blood and muscles by using the developed AMX ELISA in an in vivo microdialysis model designed for pigeons. Following i.m. injection (25 mg/kg), AMX attained a peak blood level of 4.74 +/-0.30 mu g/mL and decreased with a half-life of 2.38 +/-0.16 h. In contrast, measurements in pectoral and femoral muscles exhibited delayed appearances, reduced peak concentrations, and prolonged half-lives of 4.07 +/-0.48 (pectoral) and 3.01 +/-0.26 (femoral) that were significantly different from each other and those in the blood (P < 0.05). Blood protein binding was calculated to be 27.9 +/-5.7%. This study demonstrated the semiquantitative application of a selective AMX ELISA in the first microdialysis procedure for continuous monitoring of drug levels in specific tissues of pigeons and maybe useful for related studies in other poultry species.